SAMANTHA GAGNON BIRTH WORKER | PITT MEADOWS HOME BIRTH DOULA
  • HOME
  • About
  • Doula
  • Prenatal Education
  • Resources
    • Blog
    • 5 Ways to Discover Your Birth Wisdom
    • Birth Partner's Cliff Notes
    • 12 Pain Coping Techniques for Your Home Birth
    • Preparing your home for birth
    • My Postpartum Resources
  • bellies community space
  • Contact

Client Intake Form

Please fill out the following sections as completely as possible. Along with this client intake form, kindly read, review and sign the Service Agreement which may be accessed here.

Thank you for taking the time to fill out this form. Having this information prior to our first prenatal appointment helps me to utilize our time together more effectively and serve you better. If you have any questions, please do not hesitate to ask.

Please note, this information is private and will not be shared with any parties with out your express consent. 

    Information about you

    ​Alternate/Additional Support Person (If you have one)

    Information about your Care Providers

    Information about your pregnancy + upcoming birth + postpartum

    Because of the unique challenges of birth, it is possible that a prior trauma or violent incident can impact your birth experience. By being aware of this I can better serve you, however, please share only what you are comfortable with.
Submit
Picture
ABOUT.       DOULA.       CLASSES      BLOG.     CONTACT
Proudly supporting home birthing families in Pitt Meadows, Maple Ridge, Port Coquitlam, Coquitlam. Port Moody, Langley,
Surrey and New Westminster.

Filled with gratitude to be living and working in the unceded and ancestral home of the Katzie, Kwikwetlem, Matsqui, Kwantlen, and
​Semiahmoo First Nations.
© SAMANTHA GAGNON BIRTH WORKER  2021. ALL RIGHTS RESERVED.
Photo used under Creative Commons from Rahul De Cunha Pictures
  • HOME
  • About
  • Doula
  • Prenatal Education
  • Resources
    • Blog
    • 5 Ways to Discover Your Birth Wisdom
    • Birth Partner's Cliff Notes
    • 12 Pain Coping Techniques for Your Home Birth
    • Preparing your home for birth
    • My Postpartum Resources
  • bellies community space
  • Contact